2
S. David McSwain, MD MPH
Interim Chief Medical Information
Officer
Medical Director, Telehealth
Optimization
2018 ATA Telehealth Champion Award
Medical University of South Carolina
Charleston, SC
Julie Hall-Barrow, EdD
Senior Vice President, Network
Development and Innovation
Children’s Health
Dallas, TX
3
S. David McSwain, MD MPH has no real or apparent conflicts of
interest to report.
Conflict of Interest
4
Julie Hall-Barrow, EdD has no real or apparent conflicts of interest
to report.
Conflict of Interest
5
• Integration and Alignment
• Provider Engagement
• Process Management
• Data gaps
• Program Evaluation and Research
• Regulations and policy
• These challenges are all interwoven
– They can’t be addressed individually
– Making HIMSS slides flow by categories is hard
– Apologies to our HIMSS session mentor!
Agenda: Telehealth Adoption Barriers
6
• Define the key barriers that limit the broad adoption of telehealth
• Differentiate between barriers to technology adoption and barriers
to practice change in healthcare
• Adapt your approach to telehealth development and dissemination
to address barriers to provider adoption and utilization of
telehealth services
• Integrate an understanding of provider adoption, data and
outcomes, and collaborative development into advocacy efforts to
promote the advancement of telehealth
Learning Objectives
7
• Technology
• Patient engagement
• Great ideas
• Funding
• Reimbursement?
NOT Telehealth Adoption Barriers
8
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
9
Effective, Efficient Systems:
• People Process Tools
Healthcare System
Health Delivery System
Practice groups
Provider
Patient
Families
• People Process Tools
• People Process Tools
• People Process Tools
• People Process Tools
10
Alignment with Leadership
• Understand the goals of your
institution
– Are they looking to grow?
– Are the looking to reduce costs?
– Do they need to fill beds? Do they
need to empty beds?
– Are they in a competitive
environment?
– Are they in a fee-based or value-
based payment model?
11
Aligning vision and strategy
11
Privileged and Confidential
12
Large, Growing Market
• 1 of 9 children in U.S. live in Texas.
• 1 in every 5 children in North Texas
lives in poverty.
• 7 out of every 10 public school children
in Dallas County eligible for free and
reduced-price meals.
• The rates of uninsured children in
North Texas are 2X the national
average.
• Nearly 50% of children in Dallas
County are enrolled in Medicaid.
• Only 31% of Texas physicians accept
new Medicaid patients (down from 42%
in 2010)
Significant Pediatric Medical Needs
• More than 90,000 children in North Texas have
asthma
• 36% of Dallas County kids are overweight or obese
• 28% of Dallas County children are malnourished
• 30% of toddlers not fully immunized
Understand Your Community
Privileged and Confidential
12
13
Virtual Health at Children’s
2014
- TeleNICU
- School Telehealth
Sep
2013
Oct
2014
School
Telehealth
27 Schools
2015
Remote Patient
Monitoring
Mar
2015
Virtual
Education
Apr
2015
My Asthma Pal
App
Sept
2015
Jul
2015
TeleER
Virtual Visit
CIN/CHPG
School Telehealth
57 Schools
656 Encounters
Oct
2015
2016
Virtual Visit
CHST Occ. Health
Jan
2016
Proteus
Virtual Visit
Retail Pharmacy
School Telehealth
102 Schools
11,000+ Encounters
Sep
2016
2017
Virtual Visit
Internal Specialties
Jan
2017
TeleBehavioral
Health
13 K student
population
Sep
2017
2013
2018
GoNoodle
Zippy
(Virtual Patient
Rounding)
Aug
2014
TeleEcho
Prior
to
2013
Rank One Health
Connects 2000K+ K-
12 schools across
Texas
RPM expansion
Potential of 350+
patients – 50 current
School Telehealth
118 Schools
Sep
2018
14
Shifting Focus from Patient to Consumer
PATIENT
CONSUMER
POPULATIONS
Sources: Valence Health, Lori Palminteri
Privileged and Confidential
14
15
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
16
Provider Engagement
Providers still drive healthcare.
• Understanding what drives the providers will help you drive your program
• Provider Adoption
– Providers have been trained for years on evidence-based medicine
– Lack of an evidence base inhibits adoption
• Need evidence to get past early adopter phase
17
Challenges of Provider Adoption
Healthcare providers face ever-increasing challenges and demands on their time
– Revenue generation
– Patient throughput
– Complex documentation
– Competitive forces
– New demands
Many providers rightly see telehealth as a THREAT, not an opportunity
– Programs target “bread and butter” patient populations
– Not focusing on the real opportunities
• Chronic disease, complex patients, care coordination
18
Provider Adoption of Telehealth
Services
Well designed telehealth programs can improve provider efficiency and engagement
and improve provider and patient satisfaction.
– Fit within existing workflows
– Provide demonstrable benefit
• Identify target metrics
• Communicate anticipated impact clearly
– Focus on ease of use
• Minimize disruption
• Support services
– Robust training and education programs
19
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
20
• Knowledge management
– A hoarder of knowledge is a single point of failure
• OHIO (Only Handle It Once)
– “We’re only doing this one time.”
– Doing something once and handling something once are two
different things
• Handling it means creating a repeatable, easily disseminatable
process than can be referenced and applied in future situations.
• Effective education and training depends on the establishment of clear,
documented processes and workflows!
Process Management
21
Build in Appropriate Incentives
• Even well-designed programs may not generate significant provider adoption without
aligning incentives for the provider
• Potential Incentives
– Financial (bonus, stipend, on-call pay, etc)
– Time (FTE)
– RVUs
• ALIGN incentives to address challenges to adoption and sustainability
– Completion of encounters
– Documentation of encounters
– Adherence to established workflow
– Appropriate billing
– Completion of service evaluation tasks
– Patient satisfaction
22
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
23
Operating Procedures for Pediatric Telehealth
• Initial literature search: > 1000 articles
• Limited search: 700 articles
• Review of articles
• Many involved telephone services and
web portals
• Most were program descriptions,
feasibility studies, or satisfaction
surveys
• Very limited number of controlled trials
• “Guidelines” became “pediatric telehealth
operating procedures.”
24
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
25
Overlooked Aspect of Telehealth
Development
• Early focus of program development is on technology, workflows, and
administrative support.
• Program evaluation plan often deferred until “later.”
– Reaching a “steady state” with a program can take years.
– Developing the evaluation plan can facilitate and improve other
development
• Technology
• Communication
• Workflow
– Early data collection provides baseline data for future demonstration
of impact and clinical trials
– Describing what you hope to accomplish will help gain support
26
Barriers to Research
• Insufficient numbers
• Unstable environment
– Rapidly evolving
technology
– Program workflows
and personnel
change
• Variability across the
country
27
National Pediatric Telehealth
Infrastructure Assessment
0
5
10
15
20
25
30
35
40
45
50
Dedicated FTE
Number of Respondents
28
Integration and Alignment
Research
Program Evaluation
Provider Engagement
Policy
Regulations
Process Management
Data Gaps
29
Approach to Policy Makers
• Not all policy decisions are data-driven
• But data (and the lack thereof) can still be a
powerful driver of policy
– The Congressional Budget Office has stated
that they were unable to score many
telehealth-related bills due to a lack of
meaningful, unbiased outcomes data.
– Research and program evaluation data
increases the impact of educational and
advocacy materials
– Legislators and other policy-makers respond
very positively to UNDERSTANDABLE
scientific data
• Must present easily digestible sound bites
and talking points
30
Federal Legislation
Bipartisan Budget Act of 2018, signed into law by the President on February
9, 2018.
• The bill introduces some of “the most significant changes ever made to Medicare law
to use telehealth,” according to Senator Brian Schatz, a longtime sponsor and
proponent of federal telehealth legislation.
– (1) expanding stroke telemedicine coverage;
– (2) improving access to telehealth-enabled home dialysis oversight;
– (3) enabling patients to be provided with free at-home telehealth dialysis
technology without the provider violating the Civil Monetary Penalties Law;
– (4) allowing Medicare Advantage (MA) plans to include delivery of telehealth
services in a plan’s basic benefits; and
– (5) giving Accountable Care Organizations (ACOs) the ability to expand the
use of telehealth services.
31
• Under Section 50325 of the new bill, beginning Jan. 1, 2019, the
geographic and facility-type requirements on originating sites will
no longer apply for purposes of diagnosis, evaluation, or
treatment of symptoms of an acute stroke when delivered at
certain originating sites.
TeleStroke
32
• Under Section 50302 and effective January 1, 2019, an individual
with end stage renal disease (ESRD) receiving home dialysis may
choose to receive monthly ESRD-related oversight visits from
their home via telehealth if the patient receives a “face-to-face”
visit (in this context, meaning in-person) at least once a month
during the initial 3 months of home dialysis and then, after the
initial 3 months, at least once every 3 consecutive months.
• Free equipment for individuals for at-home dialysis.
Telehealth Dialysis
33
• MA plans have not been as quick to cover telehealth services
compared to Medicaid managed care plans.
• Section 50323 of the bill gives MA plans the ability to offer
telehealth services as part of their basic benefit package (i.e., as if
the telehealth services were benefits under the original Medicare
fee-for-service program option). However, exactly what telehealth
services will qualify as a “basic benefit” have not been fully
defined.
• Comments in November of 2018 and go into effect in 2020.
Medicare Advantage Plans Can Finally Include
Telehealth Services as a Basic Benefit
34
• Accountable Care Organizations (ACOs) have even more
flexibility to use telehealth services. Beginning January 1, 2020,
the patient’s home qualifies as an eligible originating site for
telehealth services provided by a physician or practitioner
participating in certain ACOs (Next Generation, MSSP Track II,
MSSP Track III, and certain two-sided risk models). No payment
may be made for telehealth services CMS deems to be
inappropriate to furnish in the home setting (e.g., inpatient hospital
services).
• the law eliminates the rural geographic area requirements for
ACOs (i.e., the originating site need not be located in a rural
health professional shortage area or a non-metropolitan statistical
area).
• No facility fee.
The Patient’s Home is an Eligible Originating Site for
Accountable Care Organizations
35
• The Special Registration for Telemedicine Clarification Act
• The legislation lifts the requirement that physicians must first
establish an in-person relationship before using telemedicine to
treat opioid addiction. By allowing physicians to offer MAT via
telemedicine, patients in underserved or rural areas would have
access to additional treatment options.
• Pediatrics – Medicaid ; for example a school is not recognized as
a DEA site.
Opioid Package
36
"The demand to expand telehealth practice and coverage is
high from all types of providers, from primary care physicians
who are looking to help their patients manage chronic diseases to
specialists caring for high-risk, high-cost patients," according to the
briefing. "Telehealth also holds significant potential for fields like
behavioral health, where patient populations are often high-risk and
can see significant benefits from remote, easy-to-access care.
As for the patients, their voices offer "the strongest, or perhaps most
decisive, push. As health care becomes a much more consumer-
driven field, providers, policy makers, and payers ... will have to
respond to meet patient demands, including the demand for access
to health care services provided via telehealth as a cost-effective
way to engage the health care system."
Legislation and Expansion
37
• Texas 84
th
Legislature; House Bill
1878
• Any provider can bill in a school
based telemedicine program.
• Texas 85
th
Legislature; Senate Bill
1107
• Addressed physician – patient
relationship.
Legislation and Expansion
38
Legislation and Expansion
Home as a Billable Site
39
When it goes right…
